Plan Won’t Pay for a Prescription Drug? You May Have Options

Posted by Medicare Made Clear

If you’ve ever gone to the pharmacy to pick up a prescription only to find out your drug plan won’t pay for it, it may be because it’s not on the plan’s drug formulary. If this happens to you, you can take one of the following actions.

Leave the Drug at the Pharmacy and Then Ask Your Plan for a Coverage Determination or Exception

You can leave the drug at the pharmacy counter and then ask your plan for a coverage determination. To do this; you, your representative or your doctor will need to contact your plan by phone, letter or by sending a completed Model Coverage Determination Request (found here).

If the reason your plan won’t pay for the drug is because the drug is not on the formulary, you should ask your doctor if your condition can be treated with a different medication that is on the formulary. If a different medication is not an option, you can use of one of the above methods to contact your plan to request a tiering or formulary exception. Included with the exception should be a written statement by your doctor explaining the medical reason why the exception should be approved. Your plan has 72 hours from the time it receives your written standard request to notify you of the decision.

You or your doctor can also call or write your plan for an expedited exception request if your doctor tells you or your plan that waiting for a standard decision may put your health or life at risk or seriously harm your future prognosis. Your plan has 24 hours from the time it receives your written expedited request to notify you of the decision.

Purchase the Drug with Your Own Money and Then Ask to be Reimbursed

If you purchase the drug with your own money; you, your representative or your doctor can make a standard request that your plan reimburse you for the cost of the drug. Your reimbursement request must be made in writing and mailed to your Medicare drug plan. If you are requesting an exception in addition to reimbursement, your doctor must provide a written statement explaining the medical reason why the exception should be approved. Once your plan receives your written standard request, it has 72 hours to notify you of the decision.

If the plan’s decision is still unfavorable, the notification will include information instructing you how to file a request for redetermination with your plan.

It’s a good idea to check if your medications are listed on the Part D or Medicare Advantage plan’s drug formulary before enrolling in the plan. Learn how to enroll in a Medicare drug plan during Medicare Open Enrollment.

Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies. For Medicare Advantage and Prescription Drug Plans: A Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in these plans depends on the plan’s contract renewal with Medicare.